Hypertension

More than 23 million U.S. residents between 25 and 65 are estimated to have either diagnosed or undiagnosed hypertension, based on the National Health and Nutrition Examination Survey III (Hyman and Pavlik, 2001). The rate of uninsurance for the general population in this age group is 16 percent (Table D.1). If adults between ages 25 and 65 who have hypertension are as likely to lack health insurance as the overall population in this age range, then about 3.68 million adults with hypertension can be expected to be uninsured.

TABLE D.1

Estimated excess deaths among uninsured adults 25–64 for 2000.

The RAND Health Insurance Experiment documented a 10 percent lower overall mortality risk for adults with hypertension in insurance plans with no cost sharing compared to those in plans with any cost sharing, due to better hypertension treatment (Newhouse et al., 1993). This 10 percent value is used here as an estimate of the differential overall mortality between uninsured and insured adults ages 25–64 with hypertension.² If these 3.68 million uninsured adults with hyper tension were to experience a 10 percent reduction in their mortality risk as a result of gaining health insurance, calculating from the general population mortality rate for adults ages 25–64 (3,717 per million, as presented in Table D.1), the excess deaths among uninsured adults due to unidentified and undertreated hypertension are about 1,300 or 1,400 each year (10 percent of 3,717 = 372 excess deaths/ million population, multiplied by 3.68 million = 1,369).

Breast Cancer

Approximately 40,200 women died of breast cancer in 2001, an estimated 16,560 of them under age 65 (41.2 percent of breast cancer deaths in 1997 occurred in women under age 65) (NCI–SEER, 2001). Using an uninsured rate of 7.55 percent for women diagnosed with breast cancer (the uninsured rate estimated for adults under 65 with all forms of cancer, based on unpublished Medical Expenditure Panel Survey [MEPS] data for 1997),³ the excess mortality for uninsured women with breast cancer can be calculated. Using the study findings reported in Chapter 3 of a 30 to 50 percent greater risk of dying among uninsured women (Ayanian et al., 1993; Lee-Feldstein et al., 2000; Roetzheim et al., 2000a), the number of excess deaths among uninsured women that are attributable to their higher risk is in the range of 360 to 600 each year. This estimate is conservative because it does not take into account those women who were uninsured at the time the disease developed but who gained coverage (most probably Medicaid) at some point thereafter. If the uninsured rate for all women in the 50– 64 year-old age range, 13–14 percent were used in the estimate, the number of excess deaths due to uninsurance would almost double.

HIV Infection

Approximately 20 percent of HIV-infected adults are uninsured, based on HIV Cost and Services Utilization Study interviews in 1996–1997 (Goldman et al., 2001). The 12-month mortality rate for HIV-infected adults over this same time period was 5 percent. In 1998, 12,750 deaths attributable to HIV occurred in adults ages 25–64 (CDC, 2000b). HIV-infected adults who have health insurance have been estimated to have a 71–85 percent lower risk of dying within six months than do those who are uninsured (Goldman et al., 2001). By assuming that the one-year differential mortality between insured and uninsured HIV-infected adults is similar to the six-month differential, the number of excess deaths annually among HIV-infected adults without insurance can be estimated by solving the following equation: 12,750 [actual HIV deaths in 1998] = 0.8(0.29 or 0.15)(x) + 0.2(x), where (x) is the number of deaths among uninsured adults. After solving for (x), the difference between (x) and the range represented by 0.15(x) to 0.29(x) constitutes the excess mortality among uninsured adults with HIV infection. This amounts to 1,200 to 1,500 excess deaths among the uninsured with HIV each year.